The importance of clinician-patient confidentiality in the emergency department

I've been an Emergency Medicine physician assistant for just over two years now. One of the things I enjoy most about being a PA in the emergency department is all of the different people I get to meet. The more people I meet, though, the more I realize that all humans posses certain traits that transcend all age groups, genders, and nationalities. One of the most interesting traits I've come across is humans' tendency to lie. Clinicians should always stress the importance of patient/provider confidentiality; yet even when verbalize to patients they still often lie about one thing or another.

Recently, I had a patient who tripped, fell, and sliced his head open while at work. During the suturing process, the man began to fall asleep, repeatedly jerking himself awake and apologizing profusely.

“Did you do any drugs?” I asked him. As he denied it, I became more concerned: why was this patient so somnolent? Did he have an internal head injury? When he fell asleep again and only woke up after I performed a sternal chest rub, I had to ask: “If you did any drugs or drank any alcohol, please tell me. Your behavior has me concerned for a head injury and I'm going to have to rush you over for a CT scan right now. I'm also going to perform a drug screen so I'll find out one way or another if you took any drugs today.” Again, the patient denied it, and was rushed to have CT scan. Thankfully, his CT was negative. As for his urine drug screen? Not so negative.

Had the patient been honest and upfront about his behavior, he still would have gotten a CT scan based on his altered mental status and intoxicated state, but there would have been much less trouble and stress for everyone involved.

It amazed me that, even though this patient knew he was going to get a urine drug screen, he still lied about his drug use. Unfortunately, this patient was not my first -- nor will he be my last -- to do this. When I find out that a patient is lying to me about one thing, I have to assume that they have been lying about other things as well. Are patients lying because they think we'll judge them? Are they lying because they don't think we'll find out? Are they afraid we're going to tell someone? Are they in denial? I'm guessing this patient wasn't telling the truth because he had been at work when it happened. Whatever the reason, I find it sad that patients feel the need to hide the truth.

The provider-patient relationship is protected and confidential for a number of reasons, but one of the most important is to ensure that patients feel comfortable communicating honestly and openly with medical professionals. Good information and open communication is essential for clinicians, and it is incumbent upon us to communicate clearly to patients that our conversation is confidential. I make it a point to inform my patients that I am not going to judge them, that anything they tell me is confidential, and that I need them to be honest in order to provide the best care possible as quickly as possible. I can only hope that being upfront and honest with them in the beginning will allow them to be upfront and honest with me. By doing so, I can avoid the conversation that we will inevitably have when I find out they've been lying. It will also save them time, and the occasional sternal chest rub.

Jillian Knowles, MMS, PA-C, works as an emergency medicine physician assistant in the Philadelphia area.

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